Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0189, written 6 Jun 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Jun 2019 |
|---|---|
| Reference | 2019-0189 |
| Deceased | Richard Hallett |
| Coroner | Brendan Allen |
| Coroner area | Dorset |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. |] The Duchy of Cornwall, Poundbury Farmhouse, Poundbury Farm Way, Dorchester. DT1 3RT 1 | CORONER Iam Brendan Joseph Allen, Assistant Coroner, for the Coroner Area of Dorset. 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 | INVESTIGATION and INQUEST On the 21% September 2018, an investigation was commenced into the death of Richard Stanley Lee Hallett, who was born on the 11 June 1993. The investigation concluded at the end of the Inquest on the 29" May 2019. The Medical Cause of Death was: Ta Severe Head Injury The conclusion of the Inquest was Richard Stanley Lee Hallett died as a consequence of a road traffic collision. 4 | CIRCUMSTANCES OF THE DEATH On 14 September 2018, Mr Hallett was riding a motorcycle in a westerly direction along Harewood Road in Poundbury. As he approached the junction with Lower Blackmere Road, a white Iveco van was approaching the same junction, travelling in a northerly direction along Lower Blakemere Road. Mr Hallett’s motorcycle collided with the driver's side wing of the Iveco van. He sustained severe head injuries and was taken to Southampton Hospital. Despite surgical intervention, Mr Hallett died at Southampton Hospital on 16% September 2018. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: 1. During the inquest evidence was heard that: i. There are no road markings in the Poundbury estate to indicate which vehicle has the right of way when reaching a junction. In addition, parking appears to be permitted along the length of Lower Blakemere Road, which forces vehicles travelling in a northerly direction into the oncoming carriageway. Police evidence indicated that this reduced the sightline of the driver of the Iveco van when looking into Harewood Road to look for oncoming traffic. 2. Ihave concerns with regard to the following: i. The lack of parking restrictions on Lower Blakemere Road result in the drivers that use that road having a reduced sightlines when approaching junctions. Such drivers are not able to see traffic approaching the junctions until very late, and as no vehicle would appear to have right of way, the risk of collision would appear to be increased. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, 2"? August 2019. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) Tina Cooper, mother of Richard Hallett; (2) Mr Andrew Bell, the driver of the white Iveco van mentioned above. Tam also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Dated BrendarJ Allen 6 June 2019
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
DUCHY /CORNWALL POUNDBURY OFFICE, POUNDBURY FARMHOUSE, POUNDBURY FARM WAY, POUNDBURY, DORCHESTER, DORSET DTI 3RT , Estates Director for the Duchy of Cornwall Mr B J Allen H M Acting Senior Coroner for Dorset The Coroner’s Office for the County of Dorset Town Hall Bournemouth BH2 6DY Dear Mr Allen Richard Stanley Lee Hallett Deceased Thank you for your letter of 7 June. I have carefully considered the points you have raised and can reply as follows. l.i. “There are no road markings in the Poundbury estate to indicate which vehicle has the right of way when reaching a junction. In addition, parking appears to be permitted along the length of Lower Blakemere Road, which into the incoming forces vehicles travelling in a northerly direction carriageway. Police evidence indicated that this reduced the sightline of the driver of the Iveco van when looking into Harewood Road to look for oncoming traffic.” The extent of road markings and general signage is purposely restricted as part of the highway design, with approval from Dorset Council Highways Department. The approach being to; a. Place more immediate responsibility on road users rather than reliance on markings and signage b. Establish individual engagement, including eye contact, between highway users, be they vehicular, motorcycle, cycle or pedestrian 2.i “The lack of parking restrictions on Lower Blakemere Road result in the drivers that use that road having a reduced sightlines when approaching junctions. Such drivers are not able to see traffic when approaching the junctions until very late, and as no vehicle would appear to have right of way, the risk of collision would appear to be increased.” There is no formal parking restriction in Lower Blakemere Road, in common with the majority of Poundbury. This does not alter the requirement on individuals to park safely and in accordance with the Highway Code. With the exception of the tragic incident on 14 September 2018, Dorset Council Highways have confirmed there have been no other serious occurrences at this site. I am also assured by Dorset Council and our own Highway Design Consultants, having themselves reviewed the accident data for 2014-2018 for Poundbury and Dorchester, that there does not appear to be any pattern or clustering of accidents within Poundbury which would suggest that there are not any particular ‘black spots’. However, to reduce the possibility of a repetition, I can advise that we have reviewed the location and identified measures to restrict parking in the immediate vicinity of the junction. This is proposed to be in the form of two additional parking bollards on each approach, set back from the junction, deterring cars from parking immediately by the crossing. The proposals have been submitted to Dorset Council Highways Department for approval. Subject to such approval, they will be installed as soon as practicably possible, with a longstop of 31 October 2019. 1 trust you will contact me if you require any further clarification. Yours sincerely Estates Director 2
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